Move to Get Babies Off the Bottle Doesn't Reduce Iron Deficiency

Action Points

Explain to interested patients that a brief in-office educational intervention to explain the dangers of prolonged bottle-feeding to parents of 9-month-old babies failed to reduce rates of iron deficiency at age 2.

Further explain that the intervention did produce a significant reduction in bottle use during the day and at bedtime, as well as earlier weaning and use of a sippy cup.

The trial was conducted in Canada among mostly well-educated parents visiting a single group practice in Toronto and may not be generalizable to other populations.

A brief, office-based, educational intervention about the harms of prolonged bottle-feeding for parents of 9-month-olds failed to reduce rates of iron deficiency by age 2, a Canadian study showed.

The randomized, controlled clinical trial that followed more than 200 children did, however, result in significant reductions in bottle use during the day and at bedtime, earlier weaning, and earlier use of a cup in the intervention group (P≤0.05 for all) compared with controls, Jonathon Maguire, MD, of the Hospital for Sick Children in Toronto, and colleagues reported online ahead of the August issue of Pediatrics.

The researchers said the educational intervention -- which lasted less than five minutes -- likely reduced bottle use because it was brief, had a clear message about the dangers of prolonged bottle-feeding, and expressed urgency about the need to wean the child from the bottle.

Intervention was effective because it was delivered to parents when children were young enough so their behavior could be modified with little resistance, was given to largely well-educated mothers, and endorsed by their trusted physician, the researchers wrote.

The American Academy of Pediatrics recommends bottle weaning by 15 months, although continuing bottle feeding in older children is common.

Previous interventions have not been shown to promote earlier bottle-weaning.

In the current trial, patients arriving for their routine nine-month visit at a three-physician pediatric practice in Toronto were randomized to an educational intervention for the parent or standard care. A total of 251 children were randomized; 201 children remained in the study by the end of two years.

Both groups received standardized counseling on healthy nutrition.

Parents in the intervention group were given a one-week protocol to wean their children from the bottle along with a sippy cup. They were also informed by a research assistant about the risks of continued bottle use, including tooth decay, iron deficiency anemia, iron deficiency-associated behavior problems, and poorer school achievement associated with low iron.

The intervention was repeated at the 15-month visit if the child was still using a bottle.

The primary outcome of the trial was the rate of iron depletion -- serum ferritin levels of less than 10 µg/L -- at two years.

Rates of iron depletion were similar in the two groups -- 10% in the intervention group and 13% in the control group (P=0.42), using an intention to treat analysis.

Maguire and his colleagues said there may have been no difference because of a lack of statistical power or because of contamination caused by parents in the two groups discussing the study.

Rates of milk consumption of greater than 16 ounces was also similar (16% in the intervention group versus 17%, P=0.7).

At the same time, the following outcomes were significantly reduced with the intervention (P≤0.05 for all):

Initiating use of a cup: 9 versus 12 months

Completing bottle weaning: 12 versus 16 months

Rate of bottle use during the day: 15% versus 40%

Rate of bottle use at night: 3% versus 10%

The most common reason reported by the parents for continuing bottle-feeding was that the child liked the bottle better than the cup (86.5%).

A limitation of the study may be that the study population included a large number of children with well-educated mothers, who may be more successful at effecting behavior change in their children than parents of lower socioeconomic status, the researchers noted.

Replicating the study in practice settings where parents are less knowledgeable about guidelines for bottle-feeding and milk intake guidelines may be needed to show an effect on weaning and iron stores, the authors concluded.

The study was supported by a grant-in-aid from the Danone Institute of Canada.

The Pediatric Outcomes Research Team is supported by a grant from the Hospital for Sick Children Foundation. Maguire was supported by a Canadian Institutes of Health Research fellowship.

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